Surgical Case Volume Research Articles

Failure to Rescue Female Patients Undergoing High-Risk Surgery

Female patients have higher mortality rates after high-risk surgery than male patients. It is unknown whether this mortality gap is due to different rates of postoperative complications or if complications are addressed differently by sex, causing complications to lead to death-so-called failure to rescue. To evaluate sex differences in failure to rescue across high-risk surgical procedures. This retrospective cohort study was conducted using data from Medicare beneficiaries from October 2015 to February 2020 who underwent high-risk vascular or cardiac surgical procedures, including abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement or repair. Data analysis was performed from August 2023 to March 2024. The primary exposure was patient sex. The primary outcomes were risk-adjusted rates of complications, 30-day mortality, and failure to rescue, which was defined as a death occurring after a serious complication. Categorical variables are presented as frequencies and proportions and compared using χ2 analysis. Continuous variables were tested for normality and compared using a t test. A total of 863 305 Medicare beneficiaries were included in this study cohort, of whom 304 176 (35.2%) were female. Mean (SD) age was slightly higher in female patients (74.8 [9.3] years) than male patients (73.4 [8.5] years), and female patients had more comorbidities than male patients (≥2 Elixhauser comorbidities, female: 262 809 [86.4%] vs male: 465 231 [83.2%]). Female patients were more likely to receive care at large hospitals and hospitals with a higher surgical case volume. Overall, female and male patients had similar rates of complications (female: 14.98% vs male: 14.37%; adjusted relative risk [aRR], 1.04; 95% CI, 1.03-1.05; P < .001). However, female patients had higher rates of 30-day mortality (female: 4.22% vs male: 3.34%; aRR, 1.26; 95% CI, 1.23-1.29; P < .001) and higher rates of failure to rescue (female: 10.71% vs male: 8.58%; aRR, 1.25; 95% CI, 1.22-1.28; P < .001). A similar pattern was observed when stratified by each procedure. In this cohort study among Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates of serious complications, but female patients with complications were more likely to die. In other words, clinicians fail to rescue female patients with complications after high-risk surgery more often than male patients. Improving the recognition and management of female patients' complications postoperatively may narrow the sex disparity after high-risk surgery.

Enhanced recovery after fetal spina bifida surgery: global practice.

Enhanced recovery after surgery (ERAS) protocols are multimodal evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aimed to explore whether worldwide fetal therapy centers offering prenatal myelomeningocele repair implement the ERAS principles and to provide recommendations for improved perioperative management of patients. In this survey study, a total of 53 fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for Cesarean section, gynecological oncology and colorectal surgery. Each item was awarded a score of 1 or 0, depending, respectively, on whether the center did or did not comply with that principle, with a maximum score of 20. The questionnaire was completed by 46 centers in 17 countries (response rate, 87%). In total, 22 (48%) centers performed exclusively open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offered both open and fetoscopic procedures and 10 (22%) used only fetoscopy. The perioperative management of patients undergoing fetoscopic and open surgery was very similar. The median ERAS score was 12 (range, 8-17), with a mean ± SD of 12.5 ± 2.4. Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%) and thromboprophylaxis (96%), while the lowest compliance was observed for preoperative carbohydrate loading (15%), a 2-h fasting period for clear fluids (20%), postoperative nausea and vomiting prevention (33%) and early feeding (35%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥ 11 days) hospital stay (mean ± SD, 12.9 ± 2.4, 12.1 ± 2.0 and 10.3 ± 3.2, respectively, P = 0.15). Furthermore, there was no significant association between ERAS score and surgical technique or case volume. The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardized protocols integrating ERAS principles may improve patient recovery, reduce maternal morbidity and shorten the hospital stay after fetal spina bifida surgery. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Choice of Adjuvant Radiotherapy Facility in Sinonasal Squamous Cell Carcinoma.

Undergoing surgery and adjuvant radiotherapy (aRT) at the same facility has been associated with higher overall survival (OS) in head and neck squamous cell carcinoma. Our study investigates whether undergoing surgery and aRT at the same academic facility is associated with higher OS compared with separate facilities in sinonasal squamous cell carcinoma (SNSCC). The 2006 to 2017 National Cancer Database was queried for patients with SNSCC undergoing surgery at an academic facility followed by aRT with or without adjuvant chemotherapy. Multivariable binary logistic and Cox proportional hazards regression models were implemented. Of 419 patients satisfying inclusion criteria, 299 (71.4%) underwent surgery and aRT at the same academic facility. Residence in a less populated area (adjusted odds ratio [aOR] 1.75, 95% confidence interval [CI] 1.02-2.99, p = 0.042) and surgical facility case volume (aOR 2.51, 95% CI 1.21-5.21, p = 0.014) were associated with undergoing surgery and aRT at different facilities on multivariable logistic regression adjusting for patient demographics, clinicopathologic features, and adjuvant therapy (p < 0.05). Five-year OS was higher among patients undergoing surgery and aRT at the same academic facility (64% vs. 55%, p = 0.039). Undergoing surgery and aRT at different facilities remained associated with worse OS on multivariable Cox regression (aHR 1.90, 95% CI 1.09-3.32, p = 0.023). Undergoing surgery and aRT at the same academic facility is associated with higher OS in SNSCC. Academic physicians should carefully consider the recommendation of aRT treatment facility based on the level of benefit that the patient may derive from coordinated multidisciplinary care. 3 Laryngoscope, 2024.

SP1.6 - To facilitate the consent process efficiency for high volume low complexity cases as part of GIRFT

Abstract Background Our department completes a high volume of low complexity surgical cases (appendicectomies, cholecystectomies, inguinal hernia repairs and para-umbilical hernia repairs). Each case must have a completed consent form facilitating autonomous patient informed decision-making. The list of potential risks is key, currently handwritten and not standardised. Get It Right First Time (GIRFT) highlighted the importance of clear risks documentation. (1) The aim of this study is to analyse and evaluate the risks listed in consent forms for these surgeries and their adherence to GIRFT. Method First, thirty-three department members were surveyed for a complete list of risks for each surgery. After seven suggestions a consensus was reached. Second, we prospectively collected data from 05/07/2023 to 12/10/2023, identifying patients undergoing appendicectomies, cholecystectomies, inguinal hernia repairs, para-umbilical hernia repairs and collected risks listed in consent forms, comparing them to the agreed list. Result We identified 24 appendicectomies, 14 cholecystectomies, 14 inguinal hernia repairs, 9 para-umbilical hernia repairs. The mean completeness of the list of risks was: appendicectomies 42% (min: 16%, max: 56%); cholecystectomies 37% (min: 24%, max: 50%); inguinal hernia repairs 45% (min: 28%, max: 56%); para-umbilical hernia repairs 44% (min: 24%, max: 62%). Conclusion Completeness and standardisation of risks in consent forms is vital as highlighted by GIRFT. Current practices limit surgeons in achieving this.

Leaks after laparoscopic sleeve gastrectomy: 2024 update on risk factors.

Leaks after sleeve gastrectomy remain a deadly complication significantly affecting outcomes and medical costs. The aim of the present review is to provide an updated decalogue on leak prevention. Risk factors of leakage after LSG were examined based on an extensive review of literature (in period time 2016-2024) and summary of evidence was provided using Oxford levels of evidence scale. Pathogenesis of leakage after LSG still remain related to ischemic and mechanical factors and, therefore, no new evidence has been reported. Conversely, some technical aspect of the procedure has changed: bougie size, antrum resection, staple line reinforcement, and intraoperative leak testing. Bougie size 36F is effective and safe achieving similar leakage rate compared to larger bougie sizes (EL:2) 2024 UPDATE; There is no significant difference in the leak rate between restrictive (< 6cm) and conservative (6cm) antrum resection (EL: 1) 2024 UPDATE; Surgical experience and case volume affect the leak rate more consistently than every kind of SLR (EL: 2) 2024 UPDATE; Intraoperative leak test after LSG represents a decision based on surgeon preference in absence of standardization (endoscopy, bubble test, methylene blue, indocyanine green.) and strong detection/prevention rate (EL: 3) 2024 UPDATE.

Cross-Sectional Survey of Vitreoretinal Surgery Fellowship Training in Secondary Intraocular Lens Placement.

Purpose: To assess current trends in vitreoretinal surgical fellowship training for placement of secondary intraocular lenses (IOLs). Methods: A cross-sectional survey was administered to vitreoretinal surgical fellowship graduates who completed their program between 2019 and 2023. Results: Completed responses were obtained from 70 (22.5%) of 311 eligible recipients. Training settings included academic (80%), hybrid academic/private practice (15%), and private practice (5%). During their fellowship, the majority of respondents reported 10 or fewer cases using anterior chamber (AC) IOLs (69%), 5 to 50 cases using scleral-sutured IOLs (64%), and 5 to 25 cases using sutureless scleral-fixated IOLs (52%). Most fellows (79%) did not have exposure to iris-fixated IOL placement during fellowship training. The Akreos AO60 (78%) and Envista MX60 (10%) IOLs were the most common choice for scleral-sutured placement. Most fellows (67%) placed fewer than 10 secondary IOLs through scleral tunnels. Overall, scleral-sutured IOL placement (Akreos Gore-Tex [polytetrafluoroethylene] sutured, 49%) and scleral-fixated IOLs (modified Yamane, 45%) were the preferred and most comfortable surgical techniques for recent graduates after completing training. There was a significant association between surgical case volume during fellowship training and self-reported competency for each type of secondary IOL (P ≤ .005). Conclusions: The majority of vitreoretinal surgical fellows receive limited training in the placement of AC IOLs or construction of scleral tunnels during their fellowship. Aligned with their experience during fellowship, recent graduates generally prefer implanting scleral-fixated or scleral-sutured IOLs. Analysis of trainees' exposure to various techniques and postgraduate surgical preferences may identify areas for improvement in surgical education.

What is the Case Volume of Orthopaedic Trauma Surgeons in the Military Health System? An Assessment of Wartime Readiness and Skills Sustainment.

Complex, high-energy extremity trauma secondary to explosive mechanisms has been increasingly common in modern warfare, accounting for a majority of combat wounds throughout the conflicts in Iraq and Afghanistan. Fellowship-trained orthopaedic trauma surgeons treated many of these complex injuries; however, as the number of casualties continue to decrease during a period of relative peace, a growing concern over maintaining military trauma readiness exists. The Military Health System Data Repository was queried for all Common Procedural Terminology (CPT) codes associated with 18 fellowship-trained orthopaedic trauma surgeons from 2013 to 2019. The codes were further analyzed and categorized based on common trauma subspecialty procedures such as fracture fixation of the pelvic ring, acetabulum, upper and lower extremity, peri-articular, and nonunion/malunion surgery. We used descriptive statistics to quantify both the average number of cases per surgeon per year in each of the subcategories and case volume among Military Treatment Facilities (MTFs) during the study period. We identified 7,769 CPT codes for surgical procedures throughout the study period. The most common surgical procedures performed were: removal of implant (n = 836, 11%), knee arthroscopy (n = 507, 7%), and debridement of devitalized tissue (n = 345, 4%). The total trauma subspecialty procedural codes and average cases per surgeon per year were as follows: pelvic ring (n = 54, <1 case/year), acetabulum (n = 90, 1 case/year), upper extremity (n = 1,314, 15 cases/year), lower extremity (n = 2,286, 25 cases/year), peri-articular (n = 675, 8 cases/year), and nonunion/malunion (n = 288, 3 cases/year). San Antonio Military Medical Center (SAMMC) accounted for the most fracture-related CPT codes overall (35%), while all other MTFs contributed approximately 10% or less of all fracture-related codes. These results highlight the lack of orthopaedic trauma volume at other MTFs outside of SAMMC, raising concern for maintaining military readiness during an inter-war period of relative peace. The DoD continues to make concerted efforts to maintain readiness through civilian partnerships and subsequently increase surgical case volume for military trauma surgeons. Future efforts should include an in-depth analysis of caseloads of military trauma surgeons providing care at both MTFs and civilian institutions to optimize preparedness in future conflicts.

Variability in Surgical Case Volume Performed During ACGME-Accredited Orthopaedic Foot and Ankle Fellowship Training.

Previous studies have demonstrated a positive correlation between case volume and outcomes in foot and ankle surgery. This study elucidates surgical case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic foot and ankle fellowship training in the United States. The ACGME provided case logs for orthopaedic residents and foot and ankle fellows (2018-2021). Variabilities in reported fellowship case volumes were defined as the fold-difference between 90th and 10th percentiles. Reported case volumes were compared between training cohorts with parametric tests. Case logs from 65 orthopaedic foot and ankle fellows and 3146 orthopaedic residents were included. Fellows reported 1.3- to 1.5-fold more foot and ankle cases during fellowship training than during residency training (P < .001). On average, orthopaedic foot and ankle fellows reported 405.4 cases and most were arthrodesis (17%), forefoot reconstruction (17%), mid/hindfoot reconstruction (13%), tendon repair/transfer (12%), and trauma ankle hindfoot (11%). Case categories with the highest variabilities were amputation (14.8-fold difference), infection/tumor (11.6-fold difference), arthroscopy (9.2-fold difference), and calcaneus (8.7-fold difference). Case volume benchmarks can assist trainees and faculty during orthopaedic foot and ankle training. More research is needed to determine case minimum requirements needed for autonomous practice in foot and ankle surgery. Level III.

Addressing the Cosmetic Resident Education Gap – a Junior Cosmetic Fellowship Program

Abstract Goals/Purpose Incorporating adequate aesthetic surgery training into integrated plastic surgery programs in the United States has remained a challenge for several decades.[1-4] Specifically, residents report low confidence in performing facial cosmetic procedures compared to breast and body contouring.[1-2] This becomes increasingly relevant in the setting of heightened specialty creep and the rise in demand for cosmetic procedures overall according to the 2022 ASPS procedural statistics which show a 19% increase in cosmetic surgery procedures compared to the pre-pandemic 2019 report.[5] In a survey of 257 residents, 26.4% felt confident performing a lower blepharoplasty, 25% performing a facelift, 16.5% performing an endoscopic brow lift, and 14% performing a rhinoplasty.[2] This resident-reported difficulty with facial cosmetic procedures has shown little progress over time in reported survey data despite an increase in minimum cosmetic case numbers and length of training. A comprehensive aesthetic training also includes exposure to non-surgical interventions such as neuromodulators, injectables, non-surgical body contouring and facial rejuvenation technology. Though non-invasive fat reduction (ie. cryolypolysis) and non-surgical skin tightening (ie. radiofrequency micro-needling) have increased in demand since 2019 (77% and 22%, respectively), residents rarely have hands-on exposure to these treatment modalities.[5] Several integrated plastic surgery programs have a dedicated year of professional development or research, providing an opportunity for programs to fill this gap between cosmetic surgery training and real-world demand. Methods/Technique A junior cosmetic fellowship curriculum was created at a single institution focused on increasing confidence in performing aesthetic surgery, exposure to non-surgical cosmetic procedures, and increasing exposure to the business side of private practice. The fellowship was designed for a single resident during the professional development year of integrated plastic surgery training, completed between the third and fourth clinical years. The junior fellow spent the year within a single, multi-office private aesthetics practice in both the surgical and non-surgical setting. Over the course of the first four months (July 2023 - October 2023), the clinical experience of the Stanford junior cosmetic fellow was queried. Analysis of surgical case volume and non-surgical patient load was performed. This was then used to project surgical cases anticipated to be completed by year end. This was compared to case log minimums for graduating integrated plastic surgery residents in the United States, an essential metric of assessing resident experience and competence. Financial analysis of the non-surgical treatments by the junior fellow was performed. Using the initial four-month data, projections were also estimated to determine profitability for the practice over the course of the year-long fellowship. Results/Complications Over the span of the initial four months, the junior cosmetic fellow completed 69 cases, 58% of which were breast / body and 42% of which were focused on facial rejuvenation. It is estimated that at completion of the fellowship, this projects to 207 cases, exceeding the cosmetic ACGME program requirements for graduation. Total sales generated by the junior fellow during the first four months were as follows: $22,802, $90,257, $78,563, and $75,084 USD. Therefore, total sales by year end are estimated to be $800,118 in non-surgical treatments – demonstrating expertise of the junior fellow in non-surgical procedures and also profitability for the practice. Conclusion Increasing resident comfort with aesthetic surgical and non-surgical procedures is imperative as the demand for cosmetics continues to rise. Here we highlight the creation of a junior cosmetic fellowship, designed for programs with a year of professional development in their plastic surgery curriculum, to bridge the gap of cosmetic resident education. This junior fellowship model increases overall resident comfort in aesthetics and experience with facial procedures, a known weakness in resident training. Also, the addition of a junior fellow has shown to be financially lucrative for a practice, encouraging private practice attendings to consider this teaching model. Beyond the scope of programs with a dedicated year for professional development, this fellowship model may encourage embedded fellowships or incorporating mini-fellowships of 3-6 months in aesthetic surgery into residency programs outside of the traditional chief resident cosmetic experience.

Shifts in Reduction Mammaplasty Surgical Volumes With the Emergence of a Global Pandemic.

The onset of the COVID-19 pandemic resulted in significant changes to the surgical caseload for various surgery departments across the United States. As medical institutions prioritized resources for the expected increase in patient volumes due to the SARS-CoV-2 viral infection, surgical departments saw a decrease in nonemergent and elective surgical procedures. Reduction mammoplasties, which are largely covered by insurance, are among the elective procedures that provide significant revenue to the hospital. This expected decline in procedures suggests a potential decline in revenue provided by the plastic surgery department of a hospital. The purpose of this study was to analyze the loss of revenue experienced by a single academic medical institution due to changes in breast reduction mammoplasty volumes during the COVID-19 pandemic. Upon institutional review board approval, using the Augusta University Medical Center's Financial Billing Data, 373 patients who underwent bilateral reduction mammoplasty were queried. A time horizon of March 2019 to February 2022 was used to determine the pre- and post-COVID case load and charges that were incurred. Statistical analysis to compare the prior 12 months and after 24 months of COVID was conducted using 2 samples of equal variance t test and F test confirming equal variance. There was a statistically significant increase in the number of reduction mammoplasties performed per month from the year before the onset of COVID-19 (March 2020) to the 2 years after (6.6-11.4 per month, P = 0.0024). There was a statistically significant increase in the per-month charges from the AU Health system for reduction mammoplasties for the same period ($31,780.92-$52,113.34 per month, P = 0.0054). Although there was an increase in per-month revenue from reduction mammoplasties, this increase failed to reach statistical significance ($7,059.95-$10,423.51 per month, P = 0.064). The plastic surgery department saw a statistically significant increase in reduction mammoplasty cases and subsequent charges in the post-COVID cohort. These findings suggest that the emergence of a nationwide pandemic did not necessarily lead to a decrease in the volume of nonemergent surgical cases despite an expected decrease in caseload due to the need to reallocate hospital resources. On the contrary, there was an increase in caseload suggesting that there may be other factors contributing to patients' pursuance of reduction mammoplasty post-COVID including convenience, resulting from time off due to pandemic, meeting insurance-covered reduction criteria, and projected recovery time.

162 The New Military Neurosurgeon Readiness Metric to Assess Surgical Readiness and Deployability

INTRODUCTION: The US Military Health System includes military treatment facilities (MTFs) and deployable medical providers that have a dual mission to provide a “medically ready force and a ready medical force”. During wartime, the surge in casualties provides abundant surgical case volume to train and sustain a ready medical force. In contrast, peacetime poses a major challenge to military provider readiness, where lessons learned are quickly forgotten and advancements in trauma and combat surgical care decelerate; a phenomenon coined the “Walker dip”. As such, the Defense Health Agency in 2019 mandated critical wartime specialties develop specialty-specific readiness metrics to measure and maintain skills and competencies, named Knowledge, Skills, and Abilities (KSA). The neurosurgery KSA metric was released in early 2023. METHODS: Case counts and associated KSA values were obtained for active duty (AD) military neurosurgeons and neurosurgery-capable MTFs over the last 12 months. RESULTS: The neurosurgery KSA metric is a point-based system that assigns case valuations based on five categories: cranial (70 points), spine (45), peripheral (15), endovascular (5) and minor (5). The threshold KSA value per provider is set at 8000 points annually, or 667 monthly. Threshold was selected as the average between the KSA of a typical level II trauma center annual case volume and initial ABNS certification caseload requirements. Of 51 AD neurosurgeons from 16 MTFs over a 12-month period, only three providers have monthly KSA values above threshold; all of which have duty assignments at civilian institutions. CONCLUSIONS: Less than 10% of AD military neurosurgeons are meeting readiness thresholds per the KSA metric. However, no internal/external validation has been performed. Future validation studies will be pivotal in determining metric accuracy and guide adjustments to ensure a medically capable military force.

Does surgical volume correlate with outcomes in TMJ replacement surgery?

ObjectivesTo survey oral and maxillofacial surgeons (OMS) who perform temporomandibular joint replacement (TMJR) to determine whether length of surgery, specific TMJR protocols, or the incidence of complications are related to experience and case volume. Study DesignAn anonymous electronic survey was emailed to 407 surgeon members of the American Association of Oral and Maxillofacial Surgeons, American Society of Temporomandibular Joint Surgeons, and European Society of Temporomandibular Joint Surgeons known to have TMJR experience via publications or reputation. The descriptive survey contained multiple choice and open-ended questions. Descriptive statistics were computed for each variable for data analysis. Results49 surgeons completed the survey. The average stock TMJR cases included 54.6% unilateral and 50.5% bilateral cases. The average custom TMJR cases included 50.5% unilateral and 49.5% bilateral cases. Average procedure time for stock TMJR was 2.86 hours for unilateral, and 5.30 hours for bilateral cases. The average procedure time for a custom TMJR was 2.75 hours for unilateral, and 4.87 hours for bilateral cases. Average duration of hospital stay for stock and custom TMJR cases was 1.49 and 1.41 days (unilateral), and 1.98 and 1.95 days (bilateral). ConclusionThis study provides some pilot data that demonstrates that the length of surgery, specific TMJR surgical protocols, and the incidence of complications may be related to surgeon TMJR experience and case volume. IntroductionAlloplastic temporomandibular joint replacement (TMJR) is indicated for patients with end-stage temporomandibular joint pathology.1 As with any surgery, complications may occur, however, to date the relationship between the incidence of adverse events and surgeon experience has been unreported for TMJR surgery. The orthopedic literature demonstrates that the risk of complications decreases with more surgeon experience with alloplastic joint replacements.2,3 The aim of this study was to survey OMS who perform TMJR to determine whether length of surgery, specific TMJR protocols, and the incidence of complications could be related to their TMJR experience and case volume. It is hypothesized that with more TMJR surgical experience and case volume there will be fewer complications. Materials and MethodsThe study received Institutional Review Board approval (IRB #2023-0095) by the University of Illinois Chicago Research Office of Protection of Research Subjects. The study complies with the Helsinki Declaration and Health Insurance Portability and Accountability Act of 1996 (HIPAA). An invitation to participate in an anonymous electronic survey, via Survey Monkey (http://www.surveymonkey.com), was emailed to 407 surgeon members of the American Association of Oral and Maxillofacial Surgeons (AAOMS), American Society of Temporomandibular Joint Surgeons (ASTMJS), and European Society of Temporomandibular Joint Surgeons (ESTMJS) list serves. Two weeks after the initial recruitment email was sent, a reminder email was sent to the surgeons. All potential participants were provided with 4 weeks to sign a detailed informed consent form and complete the survey.The descriptive survey contained multiple choice and open-ended questions including: practice type, years in practice, if alloplastic TMJR is preformed, if TMJR Fellowship was completed, years of TMJR practice, average number of annual unilateral and bilateral TMJR cases, number considered an annual “high volume number” of TMJR procedures, average procedure time in hours for unilateral, bilateral, stock, and custom TMJR cases, average duration of hospital stay in days, and any complications and management. Descriptive statistics were computed for each variable for data analysis. ResultsThe survey was successfully sent to 394 emails, with a response rate of 12.9%. 13 emails were returned from the original 407 emails. 49 surgeons completed the survey, and 2 surgeons replied that they did not complete the survey because they are retired. 63.27% of the responding surgeons identified as academic, 53.06% as private practice, 22.45% as both academia and private practice, and 2.04% as military (Figure 1A). 93.88% reported they perform alloplastic TMJR (Figure 1B). 79.17% had not completed a TMJR fellowship (Figure 1C). 27.08% employed TMJR surgery in their practices >26 years (Figure 2).

Assessment of the Surgical Oncology Case Volume Within the Public Sector in Tanzania.

Surgery provides vital services to diagnose, treat, and palliate patients suffering from malignancies. However, despite its importance, there is little information on the delivery of surgical oncology services in Tanzania. Operative logbooks were reviewed at all national referral hospitals that offer surgery, all zonal referral hospitals in Mainland Tanganyika and Zanzibar, and a convenience sampling of regional referral hospitals in 2022. Cancer cases were identified by postoperative diagnosis and deidentified data were abstracted for each cancer surgery. The proportion of the procedures conducted for patients with cancer and the total number of cancer surgeries done within the public sector were calculated and compared with a previously published estimate of the surgical oncology need for the country. In total, 69,195 operations were reviewed at 10 hospitals, including two national referral hospitals, five zonal referral hospitals, and three regional referral hospitals. Of the cases reviewed, 4,248 (6.1%) were for the treatment of cancer. We estimate that 4,938 cancer surgeries occurred in the public sector in Tanzania accounting for operations conducted at hospitals not included in our study. Prostate, breast, head and neck, esophageal, and bladder cancers were the five most common diagnoses. Although 387 (83%) of all breast cancer procedures were done with curative intent, 506 (87%) of patients with prostate and 273 (81%) of patients with esophageal cancer underwent palliative surgery. In this comprehensive assessment of surgical oncology service delivery in Tanzania, we identified 4,248 cancer surgeries and estimate that 4,938 likely occurred in 2022. This represents only 25% of the estimated 19,726 cancer surgeries that are annually needed in Tanzania. These results highlight the need to identify strategies for increasing surgical oncology capacity in the country.

Impact of COVID-19 on pediatric surgical practice in Taiwan: a comprehensive analysis.

The COVID-19 pandemic has profoundly impacted global healthcare systems, causing significant disruptions in various medical practices. This study focuses on the specific effects of the pandemic on pediatric surgical practice in Taiwan, a region known for its effective public health measures and proximity to the initial outbreak. The study analyzes data from January 2020 to August 2022, comparing it with historical records from January 2017 to August 2019. It examines changes in surgical case volumes, patient demographics, surgical indications, and trends in preoperative evaluations, surgical procedures, and postoperative care. The study reveals a decrease in total surgical cases from 2,255 to 1,931 during the pandemic. Notable findings include a slight increase in the average age of patients (4.81 to 5.10 years, p = 0.064), a significant shift in gender distribution towards male patients (68.9% to 73.5%, p = 0.0009), and changes in the types of surgical procedures performed, with head and neck and gastrointestinal surgeries seeing an increase. The average hospital stay lengthened, and certain specific surgical diseases, like hypospadias and liver tumors, showed an increase. However, the age distribution of pediatric surgical patients remained stable, and emergency surgical care was resiliently maintained. The findings demonstrate the adaptability of Taiwan's healthcare system in maintaining pediatric surgical care during the pandemic. The study highlights a significant gender disparity in surgical interventions and a shift towards more urgent and emergent care, reflecting the reorganization of healthcare services during this period. The study's limitations include its retrospective nature and focus on a single institution. This research contributes valuable insights into the impact of the COVID-19 pandemic on pediatric surgical practice in Taiwan. It underscores the importance of adaptable healthcare strategies in ensuring continuity and quality of care during public health emergencies. Future research should focus on multi-institutional data and prospective studies to further understand these dynamics.

Job satisfaction and practice characteristics of shoulder and elbow surgeons: a survey of American Shoulder and Elbow Surgeons society members

The purpose of this study is to assess the current trends in fellowship training, career satisfaction, practice characteristics, and surgical case volume among shoulder and elbow surgeons. A web-based, anonymous 25-item survey was sent to the membership of the American Shoulder and Elbow Surgeons (ASES) in October of 2022. Questions posed included respondent demographics, fellowship training, career satisfaction, practice characteristics, and surgical case characteristics. Descriptive statistics were performed to report demographic information, assess job and training satisfaction rates, and evaluate practice characteristics. Chi-squared and independent samples t-tests were performed to analyze satisfaction rates, job applications, and surgical case volume with regard to years in practice and practice setting. Twenty percent (243/1248) of ASES members satisfactorily completed the survey. Of the 243 ASES member respondents, 97% (236/243) stated that they would pursue their fellowship training again. Ninety-eight percent (239/243) of respondents were satisfied with their specialty choice. One-hundred percent (242/243) were satisfied with their training in shoulder. Seventy-two percent (176/243) were satisfied with their training in elbow. Seventy-four percent (179/243) were satisfied with their job availability and 85% (207/243) were satisfied with their job location. The mean total number of orthopedic surgical cases per year was 393±171. The mean total number of shoulder cases per year was 253±149. The mean total number of elbow cases per year was 41±41. Physicians who have been in practice for 11years or more were comparatively more satisfied (90% vs. 80%) with their job location (P value=.008) and job availability (81% vs. 64%, P value < .001). Additionally, senior surgeons completed more orthopedic (431 vs. 347, P value < .001) and shoulder (279 vs. 220, P value=.002) cases annually than surgeons earlier in their careers. Satisfaction rates, job applications, and surgical case volume did not associate with practice setting. The majority of ASES member shoulder and elbow surgeons are satisfied with their training, their case volume and complexity, and their specialty choice. Fewer surgeons are satisfied with their elbow training and overall elbow case volume remains low among shoulder and elbow surgeons. Shoulder and elbow surgeons earlier in their careers perform fewer surgical cases, are less satisfied with their job availability and location, and completed more job applications for their first job after fellowship when compared to more senior surgeons.

Reusable scrub caps are cost-effective and help reduce the climate footprint of surgery.

As the US healthcare sector contributes to 5-10% of national CO2 emissions, with a substantial contribution from surgical services, a collective effort is important to minimize the climate footprint of surgery. Solid plastic waste generated from single-use items in operating rooms is a major contributor to greenhouse gas emissions. To address this problem, we implemented a pilot study to replace single-use scrub caps with reusable caps. Ninety-two surgical trainees at the Massachusetts General Hospital, Boston, were provided reusable personalized scrub caps. Over 6months, their use of the reusable cap was compared with corresponding use of disposable single-use caps. We then used the cost of raw materials, fabric and cap manufacturing, transportation, and end-of-life/waste treatment to perform an economic and environmental burden analysis. After 6months of reusable scrub cap use, 33 participants (51.6%) reported that due to their use of a reusable scrub cap, their utilization of disposable bouffant or caps had decreased by 76-100%. This was associated with a significant reduction in the use of single-use caps after adjusting for surgical case volume. The carbon footprint of single-use scrub caps was significantly higher than reusable caps during the study period. Reusable scrub cap usage also strongly correlated with substantial reductions in energy consumption and freshwater toxicity. Reusable personalized cloth scrub caps are cost-effective and can help reduce surgery's carbon footprint by reducing waste generated from disposable scrub cap use. More programs should consider replacing single-use polypropylene caps with reusable scrub caps for their operating room staff.

Female pelvic medicine and reconstructive surgery fellows' case logs remained stable during the COVID-19 pandemic.

During the COVID-19 pandemic and subsequent staffing shortages there was concern about the case volume, and thus competency, of graduating trainees due to reduced surgical volumes. Elective procedures were particularly affected, which includes Female Pelvic Medicine and Reconstructive Surgery (FPMRS) cases. To understand whether FPMRS fellows were affected, we assessed their case logs for changes during the pandemic. The nationally aggregated case logs of graduating FPMRS fellows, both urology and obstetrics and gynecology (OBGYN), were obtained from the Accreditation Council for Graduate Medical Education. The available academic years (AYs) included 2018-2019, 2019-2020, and 2020-2021. Standard deviation for each index category was derived from the average and 90th percentile data. One-way analysis of variance was used to compare differences in case volumes for tracked index categories between AYs. Graduating fellows logged an average of 517.4 (standard deviation [SD] 28.6) and 818.0 (SD 37.9) cases, for urology and OBGYN respectively, over their fellowship training during the examined period. No significant differences in total surgical procedures were found for either specialty between pre-COVID AY 2018-2019 and COVID-affected AYs 2019-2020 and 2020-2021. For urology fellows, gastrointestinal (GI) procedures was the only index case category with a significant difference, and it was a decrease between the two COVID-affected AYs: 2020-2021 compared to 2019-2020 (8.9 vs. 4.2, p = 0.04). For both urology and OBGYN fellows, there was a statistically significant decrease in graft/mesh augmentation procedures from COVID-affected AY 2019-2020 to AY 2020-2021. This may be attributed to the reclassification of mesh removal cases from graft/mesh augmentation procedures to genital procedures in 2020-2021. There was not a significant decrease in these procedures from pre-COVID AY 2018-2019 to the COVID-affected AYs. There were no other statistically significant differences between AYs for OBGYN fellows. Surgical case volumes for FPMRS urology and OBGYN fellows who trained during the COVID-19 pandemic were comparable to those of their pre-pandemic peers. No significant differences between pre-COVID and COVID-affected years were found for either total surgical procedures or index case categories. Despite disruptions in health care nationwide, FPMRS trainee case volumes were largely unaffected.

Socioeconomic Disparities in the Pursuit of Care at a High-Volume Institution for Surgical Resection of Vestibular Schwannomas.

Increased institutional surgical resection case volume for vestibular schwannomas (VSs) has been associated with improved patient outcomes, including reduced risk of prolonged hospital stay and readmission. Socioeconomic disparities in the pursuit of care at these high-volume institutions remain unknown. Retrospective cohort epidemiological study. National Cancer Database, a hospital-based registry of over 1,500 facilities in the United States. Adult VS patients (age, >18 years) treated surgically. High- versus low-volume facilities, defined using a facility case volume threshold of 25 cases per year. A risk-adjusted restricted cubic spline model was previously used to identify this risk threshold beyond which the incremental benefit of increasing case volume began to plateau. Sociodemographic factors, including race, ethnicity, income, insurance status, and rurality. Multivariable analyses were adjusted for patient and tumor characteristics, including age, sex, Charlson-Deyo score, and tumor size. A totoal of 10,048 patients were identified (median [interquartile range] age = 51 [41-60] years, 54% female, 87% Caucasian). Patients with Spanish/Hispanic ethnicity (OR = 0.71, 95% confidence interval [CI] = 0.52-0.96), income below median (OR = 0.63, 95% CI = 0.55-0.73]), and Medicare, Medicaid, or other government insurance versus private insurance (OR = 0.63, 95% CI = 0.53-0.74) had reduced odds of treatment at a high-volume facility. Further sensitivity analyses in which facility volume was operationalized continuously reinforced direction and significance of these associations. Socioeconomic disparities exist in the propensity for VS patients to be treated at a high-volume facility. Further work is needed to understand the nature of these associations and whether interventions can be designed to mitigate them.

Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

Military-civilian partnerships have built the foundation for US neurosurgery as we see it today. Each conflict throughout history has led to expansion within the field of neurosurgery, benefiting civilian patients and those in uniform. Despite the field's growth during wartime, military neurosurgical case volume declines during peacetime, and as a result, important knowledge gained is at risk of being lost. The current landscape of military neurosurgery reflects the relative peacetime for the US-World relationship. Because of this peacetime, the surgical case volume and experience of the military neurosurgeon are declining rapidly. In addition to providing a history of military-civilian partnerships in neurosurgery, we have analyzed the declining case volume trends at a single military treatment facility with neurosurgical capabilities. We compared the case volume of a military neurosurgeon at a civilian partnered location with their previous volume at a military treatment facility and analyzed current trends in wartime readiness by Neurosurgery Knowledge, Skills and Abilities metrics. We believe that military civilian partnerships hold the key to scaffolding the experience to maintain the wartime readiness in the military neurosurgical community.

US patterns of care for urodynamic evaluation for BPH.

Practice patterns around the use of urodynamic evaluation (UDS) for benign prostatic hyperplasia (BPH) surgery are largely undefined. As such, we investigated factors associated with the use of UDS for BPH. We used American Board of Urology case log data from 2008 to 2020, to compare patient- and surgeon-sided factors associated with UDS utilization and BPH surgeries. We performed logistic regression models to identify factors independently associated with UDS usage for BPH. Among urologists performing UDS, the majority (80%) self-identified as general urologists and practiced in a private practice group (69%). Compared with urologists who performed no UDS, urologists who performed any UDS for BPH were more likely to be from the Mid-Atlantic (20.3% vs. 10.6%, p < 0.01) and practice in regions with populations of >1 000 000 (34.7% vs. 28.5%, p < 0.01). Overall, UDS utilization declined over time (odds ratio [OR]: 0.95 year-to-year, 95% confidence interval [CI]: 0.91-0.99). In adjusted analyses, the odds of performing UDS was higher among male (OR: 2.19, 95% CI: 1.17-4.09), older (OR: 1.05, 95% CI: 1.03-1.06), and female pelvic medicine and reconstructive surgery subspecialty (OR: 3.23, 95% CI: 2.01-5.2) urologists. Additionally, performing UDS for BPH was associated with higher BPH surgical case volume (OR: 1.004, 95% CI: 1.001-1.008). There is a significant practice variation in use of UDS for BPH. Although overall BPH surgeries are increasing, urologists are increasingly less likely to perform UDS for BPH. Specifically, urologists who perform UDS have significantly higher BPH case volume than those who do not perform UDS, suggesting that UDS usage may not factor into BPH surgery decision-making.